13.10.3.9

MANDATORY DISCLOSURES

1. A. Disclosure Required. A short-term plan shall not be offered or issued without providing the prospective insured applicant a disclosure in the form and with the content specified in this section.
2. B. Disclosure format. The standard disclosure shall be displayed prominently in the plan and in the plan application, and shall also be delivered as a separate document to the applicant upon delivery of the application.

3. C. Delivery of disclosure. The applicant must sign an acknowledgement of receipt of the form.

   1. (1) The carrier shall retain each acknowledged disclosure form for five years. Signed forms shall be available for review by the superintendent upon request.
4. (2) The standard disclosure form shall not be used until it has been filed with and approved in writing by the superintendent.

5. (3) The standard disclosure form shall include the following information and shall be presented on the first page of any application for coverage in 12-point or larger font:

   THIS IS SHORT-TERM, LIMITED DURATION HEALTH INSURANCE COVERAGE. THIS PLAN ONLY LASTS FOR [Insert Duration] AND IS NONREWABLE. THIS COVERAGE IS UNAVAILABLE TO ANY INDIVIDUAL WHO HAS BEEN INSURED BY A SHORT-TERM PLAN WITHIN THE PREVIOUS TWELVE-MONTH PERIOD.

   THIS PLAN MAY HAVE DOLLAR LIMITATIONS ON BENEFITS.

   THIS COVERAGE DOES NOT COMPLY WITH ALL AFFORDABLE CARE ACT REQUIREMENTS. TO SEE IF YOU QUALIFY FOR FINANCIAL ASSISTANCE AND ENROLL IN AFFORDABLE CARE ACT COVERAGE VISIT WWW.BEWELLNM.COM. YOU MAY QUALIFY FOR A SPECIAL ENROLLMENT PERIOD IF YOU HAVE RECENTLY LOST COVERAGE.

[13.10.3.9 NMAC - N, 10/01/2020]